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General NPI Number Information
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NPI Number | 1316919616
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Entity Type | Organization
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Legal Business Name | SOUTH OAKLAND GASTROENTEROLOGY ASSOCIATES PC
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Dates
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Enumeration Date | 02/02/2006
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Last Update Date | 10/28/2025
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Provider Practice Location Address
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Address Line | 23133 ORCHARD LAKE RD STE 200
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City | FARMINGTON
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State | MI
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Zip | 48336-3279
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Country | US
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Telephone | 248-579-9220
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Fax | 248-426-7350
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Provider Business Mailing Address
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Address Line | PO BOX 72737
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City | CLEVELAND
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State | OH
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Zip | 44192-0002
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Country | US
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Telephone | 248-579-9220
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Fax | 248-426-7350
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JOLIAN SAM KATHAWA
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Credential |
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Telephone | 248-579-9220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 5101006198
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License Number State | MI
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